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March 12, 2018

Asking the Customer on Health Policy

Douglas Holtz-Eakin

Eakinomics: Asking the Customer on Health Policy

Two main issues have dominated recent health policy discussions. On the left is the desirability and feasibility of moving past the Affordable Care Act (ACA) to a full-blown single-payer system. On the right is the need for policies to stabilize the ACA’s individual marketplaces and, if so, what combinations of Cost Sharing Reduction (CSR, or government subsidies to cover the out-of-pocket costs of low-income insurance purchasers) monies and reinsurance funds would be sufficient. These are issues that the American Action Forum (AAF) health policy team has investigated extensively.

At times, however, it is useful to move past what policy experts conclude and ask the actual customer – American voters – their policy preferences. With that in mind, AAF collaborated with OnMessage to conduct a poll of voters regarding these issues. A memo summarizing the key findings is here and the full results here.

I found three important insights. First, a single-payer system – a government-established monopoly insurer – is unpopular and unlikely. It is unpopular in that 51 percent of respondents opposed it, while 41 percent favored it, and 8 percent were undecided. Granted, this is a somewhat partisan finding as 66 percent of Democrats favored single-payer, while 78 percent of Republicans opposed it. But it is also politically unlikely because the key swing group – Independents – oppose it 55 percent to 39 percent. In addition, single-payer has problems in battleground states, where 53 percent opposed it. Finally, all of these numbers become much more anti-single-payer when respondents learn of the price tag ($3.4 to $4.4 trillion annually) or the fact that private insurance (employer or union coverage) would be illegal and taken away under single-payer.

The second major finding is that how one tries to stabilize the individual market matters. Both CSRs (58 percent to 33 percent) and reinsurance (57 percent to 33 percent) have those who favor them outweighing those who oppose them. In both cases, the top line is driven by strong favorability among Democrats, with firm disapproval among Republicans. But Republicans are unmoved or react negatively to information about the price tag for CSRs and simply do not believe that providing CSR funding would lower premiums. In contrast, while not wild about the cost of reinsurance, Republicans – along with Democrats and Independents – react strongly positively to the notion that reinsurance would stop the loss of insurance companies, provide more choices, and lower premiums. Reinsurance is good policy that is also good politics.

The third observation is that these two findings are two sides of the same coin. Americans dislike a single-payer. But across the country that is exactly what many ACA exchanges have become. It is unsurprising that they favor a reinsurance system that could reverse the trend to no choice, eliminate the de facto single payer and lower premiums.